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Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30, PowerPoint Presentation
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Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30, - PowerPoint PPT Presentation

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Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30, 2012 Samuel A. Skootsky, M.D., CMO UCLA Faculty Practice Group and Medical Group. UCLA Health System Hospital System (Acute Care, Child, Psychiatric ) 40,000 discharges

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Primary Care Innovation Model (PCIM)

Patient Centered Medical Home (PCMH)

Care Transformation Council

August 30, 2012

Samuel A. Skootsky, M.D., CMO

UCLA Faculty Practice Group and Medical Group


UCLA Health System

  • Hospital System (Acute Care, Child, Psychiatric)
  • 40,000 discharges
  • 806 Licensed Beds
  • UCLA Faculty Practice Group (1214 physicians; 247 primary care; W2 model)
  • UCLA Medical Group (Internal and External Networks & Contracting)
  • 58 faculty ambulatory practice locations/29 primary care site (additional sites coming on-line)
  • 1.6 Million visits/year
  • 2.3 million encounters/year
  • 323,000 unique patients FY12



August 2012

the ucla health system pcim journey
The UCLA Health System PCIM Journey

Design Teams

Implementation Teams

Leadership Team

Design Retreats

Practice Re-Design

Increase Covered Lives

Expanded capability






Johns Hopkins

Ascension Health

August 2012



Shaping the Future

Strategic Plan 2011-2015

Strategic Evolution

CICARE/Systemic Innovation

Cultural Evolution

CareConnect & Telehealth

Technology Evolution

Care Transformation

Health System Evolution

Primary Care

Innovation Model

Program Evolution

Planning Phase

Design Phase

Implementation Phase

Operations Phase

  • Primary Care Innovation Model
  • Increase Managed Populations
    • UCOP
    • Medicare Advantage/FFS
    • Commercial/HMO/PPO
    • MSSP “ACO” Application
  • Expand Primary Care System
  • UCLA Collaborative with others
  • Replicability Internal/External

Shaping the Future Strategic Plan 2011-2015

Organizational Design

  • Primary Care Innovation Model
  • Implementation Teams:
  • Transitions of Care
  • ED/Urgent Care
  • Community Programs
  • CMMI Innovation Funded
  • Geriatrics Dementia
  • Primary Care Innovation Model
  • Practice Re-Design (PCMH)
  • MyMeds in-office PharmD
  • Expand Primary Care System (CVS)
  • Growth Strategy
  • UCLA-MG Existing Population Management
  • CMS/CMMI Challenge
  • CMS/Shared Savings

Context: (Oct 2011 – July 2012)

August 2012

pcim progress to date pcmh
PCIM Progress-to-Date: PCMH
  • Started design Oct 2011 and on-track to have 50% of current primary care sites in PCMH practice-redesign model by end of this year, goal is all current and future sites.
  • Established method for replication (Design Team & Retreats)
  • Established new roles & and responsibilities (care coordinators and leadership)
  • Established linkages with other components of UCLA System (e.g. Transitions & ED)
  • Developed new IT support and registries (e.g. prior 24 hour ED and inpatient discharges)
  • Metrics established and being refined (e.g. facility use, panel size)

As of August 2012

August 2012

pcim progress to date other features
PCIM Progress-to-Date: Other features
  • Established Growth Strategy Design Team to frame PCIM expansions
  • Relationship with retail clinics being operationalized
  • Articulated a Value-Based Care Model (HRA-based) Phase I applicable initially to:
      • Commercial HMO (UCLA Employees)
      • Medicare Advantage HMO
      • Medicare Shared Savings Plan Implementation
  • Established collaborative with UCOP on development of new UC care medical plan that includes features of PCIM & HRA-based models

HRA-based =Health Risk Assessment & biometric screening & coaching model

As of August 2012

August 2012

value based care hra based model for enrollee
Value-Based Care: HRA-based model for Enrollee

HRA, Health & Biometric Screenings

& Risk Assessment

Choose a Primary Care Provider

Health Coaching/

Linkage to

Care Coordination




Aim” & IOM

“Triple Aim” and IOM Guidance

Medical Home/ Establish PCP System/



Utilization & Formulary Compliance

Chronic Condition


August 2012

primary care innovation model team members
Primary Care Innovation Model Team Members
  • Samuel Skootsky, MD, Chair, FPG CMO
  • Jordan Hall, FPG Director Care Coordination
  • Laurie Johnson, FPG Dir Ambulatory Services
  • Molly Coye, MD, Chief Innovation Officer
  • Patricia A. Kapur, FPG CEO
  • Stephanie McCutcheon, Innovation Advisor


  • Mark Grossman, MD, Medical Director CPN
  • Christina Catipay, Director Operations
  • Donna Robinson, CPN Brentwood Manager
  • Patricia Alarcon, CPN W. Washington Manager
  • Jeff Bernal, CPN Manhattan Beach Manager


  • Bernard Katz, MD Medical Director
  • Mark Needham, MD Medical Director
  • Lorena Douille, Director Operations
  • Celina Lomeli, 20th St. Manager
  • Jessika Harris, Ocean Park Manager

Family Medicine

  • Michelle Bholat, Medical Director
  • Lynne Stevens, NP
  • Wendy Songer

Medicine-Geriatrics Internal Medicine

  • Matteo Dinolfo, MD, Medical Director
  • David Reuben, MD Chief of Geriatrics
  • Brandon Koretz, MD Medical Director
  • Lillian Martinez, Director Operations
  • Tony Michaelis, Director Operations
  • Mari Lynne Kennedy, Med Suite 455/490 Manager
  • Joe Brown, Medicine SM Internal Med
  • Eve Glazier, MD Medical Director
  • Janet Pregler, MD Ambulatory Director

Additional Team Members

  • Debora Davis, RN, BSN, CCM Managed Care
  • Alice Kuo, MD, Medicine
  • Sandra Lavin, RN, Managed Care
  • Janine Knudsen, MHA, Innovation Intern, Harvard
  • Anahit Khacheryan, Ed Dir Oper Improvement
  • Shirley Wong, PharmD, MYMEDS
  • Richard Maranon, MSA Geriatrics, MYMEDS
  • Gerardo Moreno, MD, Family Medicine, MYMEDS
  • Shawn Lee & Albert Duntugan, Dir Business Analytics
  • Beth TenPas & Kaiding Zhu Decision Support & Fin Srvs
  • Marcia Colone & Mary Noli, Care Coordination
  • Nasim Afsar, MD, Dir Quality/Safety/Medicine
  • Crystal VanDeventer, Innovation Model Support
  • Others

August 2012

pcmh pilot practices
PCMH Pilot Practices
  • Started Five Pilots (33,000 patients)
    • Santa Monica Bay Physicians Plaza Office
    • CPN Parkside SM Office
    • Family Medicine SM Family Health Center
    • Department of Medicine SM 2020
    • Department of Medicine SM Geriatrics
  • Department of Pediatrics has separate related program
  • Nolack of provider and staff enthusiasm!

August 2012

expansion sites sep 2012 start
Expansion Sites/ Sep 2012 Start

New Cohort of Eight Practices & Lead MD

  • SMBP/20th Street 3rd Floor - Michael Nagata, MD and Caroline Close, MD
  • SMBP/Ocean Park - Richard Ross, MD
  • SMBP/20th Street 10th Floor - Richard Greenspun, MD
  • CPN/Brentwood - Dr. Mark Grossman
  • CPN/W Washington - Dr. Soheil Azimi
  • CPN/Manhattan Beach - Dr. Thuy Tran
  • Med/Primary Care Suite 455/490 – TBN
  • Med/ SM Internal Medicine Lead - Eve Glazier, M.D.

With this expansion, will have total 13 sites in program

Represents 50% of all Adult Primary Care Sites

August 2012

ucla population management plan
UCLA Population Management Plan
  • Ensuring Care Implementation in the Community & at Home
  • Home Social/Environmental Factors
  • Patient Coaching
  • Transitions of Care
  • Use of Community Resources
  • Comprehensive Care Centers

Traditional Benefit-Based Home Health

Patient- Centered Shared Decision Making

SNFist and SNF Program

Optimal Discharge (Hospital, ER, SNF, other)

  • Hospital & Hospitalist-Extensivist Programs
  • Communication
  • Care Transitions
  • ER interventions
  • Efficient hospital use

“System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health

August 2012

what does practice re design mean
What does Practice Re-Design mean?
  • Defined practice populations by MD and Site
  • Having timely & actionable data
  • Team based care
    • Risk prioritization, practice huddles, care coordination, transitions management, and navigation-“linkages” within Health System
  • Advanced Primary Care Practice
    • Continuity
    • Access
    • Active Panel Management

Primary Care Innovation Model

August 2012

what is medical home functionality
What is Medical Home Functionality?

Physician or other Providers

Care Coordination

Medical Assistant/LVN

Office Manager

Case Management

Office Staff

Panel Management

August 2012


Our approach embraces “System” attributes and synergy

Health System

PCMH 2.0



August 2012

practice re design advanced primary care and health system re design pcmh
Practice Re-Design, Advanced Primary Care, and Health System Re-Design = PCMH

UCLA Health System

ED Services

Hospitalist Program

Needed Specialists and Ancillaries

Defined Care Management

MD Led Team:

Advanced Primary Care/PCMH Practice

Clinical Advisor-

Case manager

New FTE and roles noted in light green

Physician &


Other staff

ED Services




In-home services, including palliative care

Advanced Medication


Urgent Care Centers & Retail clinics

August 2012

ucla pcmh pcim metrics of success
UCLA PCMH/PCIM Metrics of Success
  • Reduction in Facility Use (increase use of alternatives)
    • Discharges & optimal LOS
    • All cause readmissions
    • ED visits
    • Ambulatory Care Sensitive Admissions
  • Generic Drug Use
  • Attenuation or Reduction in “Total Cost of Care”
  • Quality measures (standardized, valid, nationally endorsed) at 90th%tile
  • Patient Experience (Clinician Group - CAHPS) at 90th%tile
  • Provider & Staff Satisfaction (maintaining the workforce)
  • Increased efficiency in operations (e.g. panel size)
  • Success of care coordination system

August 2012


Practice & Patient Care Gaps and Registries

Action Lists = Care Gaps

Registries = Whole Population

August 2012


PCIM Population Access Mednet Site

Recent addition:

Past 24 hour ED discharges, Inpatient Admissions & Discharges

August 2012

layered approach to pcim population management
Layered approach to PCIM population management



Commercial Plan ACO

MSSP: Government sponsored ACO

Delivery System Reform Incentive Payments (DSRIP) and PCMH expansion

Expand 30+ year history of UCLAMG capitation [Medicare Advantage and Commercial] & “wrap around” population & care management

August 2012